• ACCIDENT / INCIDENT REPORT

     HS1 Accident/Incident Report Issue 1 - October 2019 

  • Part A

    Part A - WHAT IS BEING REPORTED?

  • Part A - WHAT IS BEING REPORTED?

  • Dangerous Occurrence (Defined under RIDDOR)**

    There are specific types of Dangerous Occurrence, defined by the HSE.  If in doubt contact your Health & Safety Manager or look at the HSE website for more information. http://www.hse.gov.uk

  • Part B

    Part B - About the Accident / Incident

  • When did it Happen?
     - -
    4 digit year, 2 digit month, 2 digit day :

  • Part C

    Part C - about the affected person (if there is no injury or ill health - go to Part E)

  • Is the affected person male or female?

  • Part D

    Part D - about the injury or ill health condition

  • Who gave the treatment?
  • First date of absence following the accident/incident
     - -
    4 digit year, 2 digit month, 2 digit day
  • If yes, when did they return?
     - -
    4 digit year, 2 digit month, 2 digit day

  • Part E

    Part E - describing what happened

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  • Part F

    Part F – Supervisors Investigation

  • Part G

    Part G - about any witnesses

  • If more than one witness, add others details in comments box at the end

  • Part H

    Part H – recommendations to prevent a similar incident

  • Part I

    Part I - about the person completing this report

  •  -
  • Date Reported
     - -
    4 digit year, 2 digit month, 2 digit day
  • Signature

  • The form should be completed and signed by

    ·  The immediate supervisor of the injured person or the person supervising the work or

    ·  The person in charge of the area where the accident happened

    ·  Printed and countersigned by the reporting persons manager

     

    The completed form should be sent to the UK Support Services Director and the Health & Safety Manager within 48 hours of the accident – accidents@tructyre.co.uk. This will happen automatically when you submit this eForm

    Serious accidents should be reported immediately by telephone to the Health and Safety Manager or UK Support Services Director.

    If appropriate, obtain signed statements from the injured person and from any witnesses giving their accounts of what happened and attach them to this report.  (If you are unsure as to whether statements are needed, please discuss with the Health and Safety Manager - a serious accident or one resulting in more than 7 days absence from the workplace will usually require statements.)  If statements cannot be obtained immediately, if for example the injured person has gone to hospital, do not delay completing this form and informing the Health and Safety Manager about the accident

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